Physician Deficiency Analysis and Report Prior to beginning work on this assignment, read the Health Information Management Department Suspension Policy and Procedure for Delinquent Medical Records (L

Physician Deficiency Analysis and Report Prior to beginning work on this assignment, read the Health Information Management Department Suspension Policy and Procedure for Delinquent Medical Records (L
POLICY AND PROCEDURE Policy Number: 18.08 Revised Date: 02 /2020 DEPARTMENT: Medical Staff Policy SUBJECT: Delinquent Medical Records Page 1 of 2 I. PURPOSE Medical records need to be completed on a timely basis for continuity of patient care, third party reimbursement, quality assurance, and compliance with regulatory agencies. All medical staff members are responsible for completing their medical records according to the periods outlined in this policy, the medical staff bylaws and rules and regulations. II. DEFINITIONS/APPLICATIONS 1. A delinquent medical record is defined by the following timeframes: A. History & Physical – must be completed within 24 hours of admission date B. Brief Operative Note – must be completed before leaving the OR/transferring the patient to the next level of care C. Operative Report – must be completed within 24 hours of surgery D. Verbal Order – must be completed within 24 hours of order place ment E. Discharge Summary – must be completed within 168 hours of discharge date 2. Suspension will occur if a medical record is delinquent at or over 30 days. 3. Delinquent medical records will subject the practitioner to the suspension of the following privileg es: A. New Admissions B. Scheduling of New Surgical/Procedural Cases C. Performing Consultations III. PROCEDURES 1. The health information management department will send weekly first, second, and third delinquency letters notifying practitioners of all incomplete medical records. Distribution of the letter will be by electronic delivery to the practitioner’s Epic in basket. 2. The health information management department will send an eligible for suspension letter notifying practitioners of all incomplete medical records at or over 25 days delinquent. POLICY AND PROCEDURE Policy Number: 18.08 Revised Date: 02 /2020 DEPARTMENT: Medical Staff Policy SUBJECT: Delinquent Medical Records Page 2 of 2 3. Failure to complete delinquent medical records within 30 days will result in suspension. The health information management department will send a suspension letter notifying practitioners of suspension . 4. The medical record suspension list will be updated weekly. The suspension list will be published weekly and sent to administration, medical executive committee , admitting, eme rgency department, opera ting room, nursing, department, compliance, and medical staff management. 5. The medical record suspension list is updated continually based upon the practitioner’s completion of their delinquent medical records and authorization by t he health information management director/manager. IV. RESPONSIBILITY 1. It is the practitioner’s responsibility to inform the hospital of their preferred covering provider if an emergency patient admission is required during an active suspension. The practitioner will complete the designated coverage form for this purpose and obtain the covering provider’s signature. This form will be kept in administration, admitting, and health information management. a. Suspended practitioners will not be allowed to as sume care of or transfer attending responsibility back to themselves until all delinquent medical records have been completed. 2. It is the practitioner’s responsibility to inform the medical staff office in advance of any unavailability due to vacation or l eave of absence. When practitioners plan to be absent, they must complete all delinquent medical records prior to their departure. 3. A practitioner’s failure to comply with completion of delinquent medical records will affect the status of the practitioner’ s privileges. 4. The Regional Director and Manager of Health Information Management should use all necessary authority to implement this policy, enforce it, and assess its effectiveness. Questions regarding this policy should be addressed to the Regional Dir ector or Manager. Date Created: 06/12/2012 MEC Approved: 06/13/2012 Effective Date: 08/12/2012 Revised MEC Approved: 09/11/2013 Revised MEC Approved: 09/20/2017 Revised MEC Approved: 02/ 19 /2020
Physician Deficiency Analysis and Report Prior to beginning work on this assignment, read the Health Information Management Department Suspension Policy and Procedure for Delinquent Medical Records (L
Hilltop Community Hospital Incomplete Health Records as of April 5, 20XX Patient # Patient Last Name, First Name Discharge date Provider Days since Discharge (To be completed by student) Type of Notice Sent a. Reminder b. Pending Suspension c. Suspension (To be completed by student) 123569 Gilmore, Sam 3/31/20XX Murphey 845912 Perry, Luke 3/15/20XX Roark 214596 Danes, Luke 3/12/20XX Linguini 132574 Moouse. Minnie 4/4/20XX Linguini 984136 Asane, Mark 4/1/20XX Murphey 256984 Mitchell, William 4/02/20XX Ness 312578 Samson, David 3/29/20XX Roark 978452 Moore, John 3/1/20XX Oakland 159745 West, John 3/5/20XX Peters 342589 Wessica, Jane 319/20XX Murphey 145879 Dimitrov, Jessica 3/24/20XX Peters 374589 Perkope, Dwight 3/14/20XX Linguini 246781 Manikane, Bonnie 3/15/20XX Roark 258943 Thomas, Tim 3/28/20XX Ness 012458 Richards, Mary 3/15/20XX Oakland 054896 Christie, Agatha 4/4/20XX Roark 100245 Ebright, Monica 3/15/20XX Oakland 784593 Posbig, Mike 3/22/20XX Murphey 11225578 Koltank, Cynthia 3/1/20XX Linguini 3745891 Schmidt, Tami 3/26/20XX Linguini 899814 Lostness, Peter 3/19/20XX Roark